Acute renal failure during interferon treatment

Association of thrombotic microangiopathy with interferon therapy for hepatitis B: a case report

BACKGROUND

Thrombotic microangiopathy is characterized by microangiopathic hemolytic anemia, thrombocytopenia, and organ injury. The pathological features include vascular damage that is manifested by arteriolar and capillary thrombosis with characteristic abnormalities in the endothelium and vessel wall. Thrombocytopenia is one of the common adverse effects of interferon therapy. However, a more serious but rare side effect is thrombotic microangiopathy.

CASE PRESENTATION

We report the case of a 36-year-old Asian male patient with clinical manifestations of hypertension, blurred vision, acute renal failure, thrombocytopenia, and thrombotic microangiopathy. Renal biopsy showed interstitial edema with fibrosis, arteriolar thickening with vitreous changes, and epithelial podocytes segmental fusion. Immunofluorescence microscopy showed C3(+), Ig A(+) deposition in the mesangial region, which was pathologically consistent with thrombotic microangiopathy renal injury and Ig A deposition. The patient had a history of hepatitis B virus infection for more than 5 years. Lamivudine was used in the past, but the injection of long-acting interferon combined with tenofovir alafenamide fumarate was used since 2018. The comprehensive clinical investigation and laboratory examination diagnosed the condition as thrombotic microangiopathy kidney injury caused by interferon. After stopping interferon in his treatment, the patient's renal function partially recovered after three consecutive therapeutic plasma exchange treatments and follow-up treatment without immunosuppressant. The renal function of the patient remained stable.

CONCLUSIONS

This report indicates that interferon can induce thrombotic microangiopathy with acute renal injury, which can progress to chronic renal insufficiency.

Interferon Induced Focal Segmental Glomerulosclerosis

Behçet's disease is an inflammatory disease of unknown etiology which involves recurring oral and genital aphthous ulcers and ocular lesions as well as articular, vascular, and nervous system involvement. Focal segmental glomerulosclerosis (FSGS) is usually seen in viral infections, immune deficiency syndrome, sickle cell anemia, and hyperfiltration and secondary to interferon therapy. Here, we present a case of FSGS identified with kidney biopsy in a patient who had been diagnosed with Behçet's disease and received interferon-alpha treatment for uveitis and presented with acute renal failure and nephrotic syndrome associated with interferon.

Analysis of renal function during telaprevir-based triple therapy for chronic hepatitis C

Telaprevir (TVR) is used for the treatment of chronic hepatitis C in a combination therapy with pegylated-interferon and ribavirin. Although renal dysfunction is one of the critical adverse outcomes of this treatment, little is known regarding the mechanism of its onset. The present study assessed the association of renal function with TVR dose and viral response. Hematological, biochemical, urinary and virological parameters of renal function were examined during the TVR-based triple therapy of patients infected with hepatitis C virus (HCV) genotype 1b. Serum creatinine levels were increased and the estimated glomerular filtration rate (eGFR) was decreased in every patient during TVR administration, but these values recovered to normal levels following cessation of TVR. Fractional excretion of sodium was <1% at days 3 and 7, appearing similar regardless of baseline renal function. Urinary β₂-microglobulin levels were elevated and were significantly higher in patients with renal dysfunction, as compared with those not exhibiting renal dysfunction (P<0.05). The reduction in renal function was milder in patients treated with a reduced TVR dose, and these patients had a significantly lower risk of developing renal dysfunction (P<0.05). Using a multivariate analysis, TVR dose and eGFR at the initiation of treatment were identified as significant contributory factors in the development of renal dysfunction. Reduction in TVR dose did not lead to a significant increase in the viral kinetics of HCV or detrimental effects on the sustained viral response (SVR) rate. It is hypothesized that renal dysfunction during TVR treatment is caused by damage of the renal tubule, in addition to pre-renal dysfunction, and that reduction in TVR dose reduces the rate of renal dysfunction without causing a significant decrease in the SVR rate.

Acute tubular necrosis following interferon-based therapy for hepatitis C: case study with literature review

BACKGROUND/AIMS

Interferon treatment of malignant or viral diseases can be accompanied by various side-effects including nephro-toxicity.

METHODS

We report on a 68-year-old Caucasian male who received dual therapy with pegylated interferon 2a plus ribavirin for chronic hepatitis C.

RESULTS

After three months of antiviral therapy, the patient developed acute kidney failure (serum creatinine up to 6 mg/dL) with mild proteinuria (500 mg daily) and haematuria. Immediate immunosuppressive therapy with high-dose intravenous steroids did not improve kidney function. Kidney biopsy was consistent with acute tubular necrosis without glomerular abnormalities. He started long-term peritoneal dialysis (four regular exchanges) to provide both dialysis adequacy and ascites removal. Kidney function gradually improved over the following months (serum creatinine around 2 mg/dL) and peritoneal dialysis was continued with two exchanges daily. The temporal relationship between the administration of the drug and the occurrence of nephro-toxicity, and the absence of other obvious reasons for acute tubular necrosis support a causative role for pegylated interferon; benefit on kidney disease was noted after withdrawal of antiviral agents. An extensive review of the literature on acute tubular necrosis associated with interferon-based therapy, based on in vitro data and earlier case-reports, has been made. The proposed pathogenic mechanisms are reviewed.

CONCLUSIONS

Our case emphasizes the importance of monitoring renal function during treatment of chronic hepatitis C with antiviral combination therapy as treatment may precipitate kidney damage at tubular level.

Thrombotic microangiopathy associated with use of interferon-beta

Interferon-beta is widely used for the treatment of relapsing multiple sclerosis. The drug is usually well tolerated, but autoimmune adverse effects, including kidney disease, have been reported. Only a few cases of hemolytic uremic syndrome-thrombotic microangiopathy associated interferon-alpha have been described so far, and even fewer with beta-interferon. We report a patient who developed thrombotic microangiopathy during treatment with interferon-beta and improved after discontinuation and steroid therapy. Complement cascade and antiphospholipid antibodies are investigated. The spectrum of renal diseases associated with interferon-beta treatment is also reviewed.

Treatment with IFN-{alpha}, -{beta}, or -{gamma} is associated with collapsing focal segmental glomerulosclerosis

BACKGROUND AND OBJECTIVES

Treatment with IFN is rarely associated with nephrotic syndrome and renal biopsy findings of minimal-change disease or FSGS.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

We report 11 cases of collapsing FSGS that developed during treatment with IFN and improved after discontinuation of therapy.

RESULTS

The cohort consists of seven women and four men with a mean age of 48.2 yr. Ten of the 11 patients were black. Six patients were receiving IFN-alpha for hepatitis C virus infection (n = 5) or malignant melanoma (n = 1), three were receiving IFN-beta for multiple sclerosis, and two were treated with IFN-gamma for idiopathic pulmonary fibrosis. After a median and mean [corrected] duration of therapy of 4.0 and 12.6 months, respectively, patients presented with acute renal failure (mean creatinine 3.5 mg/dl) and nephrotic-range proteinuria (mean 24-hour urine protein 9.7 g). Renal biopsy revealed collapsing FSGS with extensive foot process effacement and many endothelial tubuloreticular inclusions. Follow-up was available for 10 patients, all of whom discontinued IFN. At a mean of 23.6 months, nine of 10 patients had improvement in renal function, including one with complete remission and two with partial remission. Among the seven patients with available data, mean proteinuria declined from 9.9 to 3.0 g/d. Four of the seven patients were treated with immunosuppression, and there was no detectable benefit.

CONCLUSIONS

Collapsing FSGS may occur after treatment with IFN-alpha, -beta, or -gamma and is typically accompanied by the ultrastructural finding of endothelial tubuloreticular inclusions. Optimal therapy includes discontinuation of IFN.

Renal disease in patients with cancer

Kidney disease is very common in patients with cancer. Nephrologists are vital members of the multidisciplinary care team for these patients. Given the high prevalence of comorbidities in patients treated for active malignancy, it is not surprising that these individuals frequently develop renal diseases that are common among other hospitalized patients, such as those arising from sepsis, hypotension or use of nephrotoxic agents (e.g. radiocontrast or antimicrobial agents). The role of the nephrologist in these cases differs little with respect to the presence or absence of cancer. On the other hand, there are several renal syndromes that are unique to patients with cancer, being caused either by the cancer itself or by its treatment. These syndromes are reviewed here. In addition, patients who are receiving chemotherapy often require dialysis for either acute or chronic kidney disease. Unfortunately, there is very little information on the clearance characteristics of most chemotherapeutic agents. In cancer patients with renal disease, both the timing of administration and the dose-adjustment of chemotherapy must rely on clinical experience and close clinical observation.

IFN-alpha induces barrier destabilization and apoptosis in renal proximal tubular epithelium

Type I IFNs, like IFN-alpha, are major immune response regulators produced and released by activated macrophages, dendritic cells, and virus-infected cells. Due to their immunomodulatory functions and their ability to induce cell death in tumors and virus-infected cells, they are used therapeutically against cancers, viral infections, and autoimmune diseases. However, little is known about the adverse effects of type I IFNs on nondiseased tissue. This study examined the effects of IFN-alpha on cell death pathways in renal proximal tubular cells. IFN-alpha induced apoptosis in LLC-PK1 cells, characterized by the activation of caspase-3, -8, and -9, DNA fragmentation, and nuclear condensation. IFN-alpha also caused mitochondrial depolarization. Effector caspase activation was dependent on caspase-8 and -9. In addition to apoptosis, IFN-alpha exposure also decreased renal epithelial barrier function, which preceded apoptotic cell death. Caspase inhibition did not influence permeability regulation while significantly attenuating and delaying cell death. These results indicate that IFN-alpha causes programmed cell death in nondiseased renal epithelial cells. IFN-alpha-induced apoptosis is directed by an extrinsic death receptor signaling pathway, amplified by an intrinsic mitochondrial pathway. Caspase-dependent and -independent apoptotic mechanisms are involved. These findings reveal a novel aspect of IFN-alpha actions with implications for normal renal function in immune reactions and during IFN-alpha therapy.

Interferon-alpha-induced focal segmental glomerulosclerosis in chronic myelogenous leukemia: a case report and review of the literature

Chronic myelogenous leukemia (CML), hepatitis C, and interferon alpha (IFNalpha) have all been associated with renal dysfunction. In this paper we present a patient with the diagnosis of nephrotic syndrome and a known history of hepatitis C who received IFNalpha therapy for newly diagnosed CML. The renal biopsy showed focal segmental glomerulosclerosis, which has only been previously reported in two cases of CML treated with IFNalpha. There have also been two cases of patients with hepatitis C associated with focal segmental glomerulosclerosis. Despite the underlying hepatitis C, this case represents renal abnormalities consistent with IFNalpha therapy for CML.

Nephrotoxicity of interferon alfa-ribavirin therapy for chronic hepatitis C

The nephrotoxicity associated with interferon therapy for chronic hepatitis C infection has not been clearly defined. We describe a patient with chronic hepatitis C infection who developed the nephrotic syndrome during treatment with interferon and ribavirin. Renal biopsy revealed focal segmental glomerulosclerosis. She had a virologic and biochemical response to the antiviral therapy, and the nephrotic syndrome improved after termination of antiviral therapy. We place our case report in context with a review of the literature on nephrotoxicity associated with interferon therapy. Because our patient had no other obvious reason for the nephrotic syndrome, we are postulating that it may be secondary to interferon-ribavirin therapy. The temporal relation between the administration of the drug and the detection of toxic affects (nephrotic syndrome) and subsequent improvement upon withdrawal also supports a causative role for interferon-ribavirin. Although nephrotoxicity is rare, it should be emphasized that it can occur anytime after the start of interferon therapy, and physicians treating patients with chronic hepatitis C must be aware of this idiosyncratic, unpredictable, and potentially serious adverse event.

Glomerular and extraglomerular immune complex deposits in a bone marrow transplant recipient

A 44-year-old man developed nephrotic syndrome 9 months after HLA-identical sibling bone marrow transplantation. Membranous changes consisted mainly of alterations of glomeruli, which were interpreted as chronic graft-versus-host disease (GVHD) caused by lodging of the circulating immune complex. In the tubules, a lumpy deposition of IgG and complement breakdown products was distributed along the tubular basement membrane, which coincided with the peculiar deposits ascertained by electron microscopy. These findings suggest that an extraglomerular reaction should be considered in evaluating renal involvement of GVHD.

Thrombotic microangiopathy associated with alpha-interferon therapy for chronic myelocytic leukemia

A 31-year-old man diagnosed as having chronic myelocytic leukemia (CML) developed renal insufficiency with nephrotic-range proteinuria during alpha-interferon (IFN) therapy for CML. A renal biopsy specimen showed remarkable thrombotic microangiopathic lesions resembling those of hemolytic-uremic syndrome. The patient had papules on both lower legs, and a cutaneous biopsy showed similar microangiopathic lesions in dermal and subcutaneous vessels. Although discontinuation of IFN and initiation of prednisolone therapy resulted in resolution of proteinuria, renal insufficiency persisted. These findings suggest that long-term IFN therapy can induce late-onset thrombotic microangiopathy in systemic microvessels.

Uncommon side-effects of interferon

Beside the clinical manifestations usually observed during the treatment of chronic viral hepatitis with interferon, a small number of side-effects, less frequent and sometimes unexpected, have been described. These neurological, pulmonary, metabolic, cardio-vascular or psychiatric manifestations are uncommon but potentially severe. We here describe three cases of stroke that occurred during treatment with interferon in which the role played by the molecule could be questioned.

[Nephropathies caused by interferon alpha: apropos of 2 cases]

Two cases reports of interferon alpha-associated nephropathy are reported. The first observation is a membranoproliferative glomerulonephritis and the second a renal microangiopathy. The different cases in the literature are reviewed and the pathophysiology is discussed.